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| Case analysis on ICD-10 coding for premature rupture of obstetric membranes in a hospital from January to June 2021 |
| Rao Yi |
| Chongqing University Fuling Hospital, Chongqing 408099, China |
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Abstract Objective To summarize the methods and ideas of accurate coding for premature rupture of membranes, so as to improve the coding accuracy of premature rupture of membranes.Methods I retrieved medical records with ICD-10 code O42 as the main diagnosis in the obstetrics department of a hospital from Jan. 1st, 2021 to June 30th, 2021. According to the international classification code of diseases (ICD-10) rules and combined with relevant clinical medical knowledge, the accuracy of the classification code of premature rupture of membranes on the first page of each medical records was reviewed and analyzed one by one, and the error types and factors leading to errors were statistically analyzed.Results There were coding errors in 38 medical records, with an error rate of 33.63%. The main reasons of the errors were shown as follows: carelessness and lacking knowledge of clinical and coding rules of the coders; poor mastery of the main principles of obstetrics diagnosis and inaccurate writing of medical records of clinicians.Conclusion It is necessary to improve coding accuracy by strengthening the construction of the coding team, controlling coding quality as well as training coders and clinicians.
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Received: 01 March 2022
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［1］刘爱民．医院管理学：病案管理分册［M］．2版.北京：人民卫生出版社，2011．
［2］孙鹏．某院2014年产科病案编码质量的分析［J］．中国病案，2015，16(10)：40-41．DOI:10.3969/j.issn.1672-2566.2015.10.018.
［3］徐卫平．子宫破裂ICD编码分析［J］．中国病案，2017，18(11)：40-42．DOI:10.3969/j.issn.1672-2566.2017.11.016.
［4］谢幸，孔北华，段涛．妇产科学［M］．9版．北京：人民卫生出版社，2018.
［5］冉雨鑫，尹楠林，漆洪波．ACOG《胎膜早破临床实践指南(2020)》解读［J］．中国实用妇科与产科杂志，2020，36(8)：736-739．DOI:10.19538/j.fk2020080115.
［6］沈晓蓉，李晓丽，孔彬．产科凶险性前置胎盘ICD-10编码案例分析［J］．江苏卫生事业管理，2021，32(5)：625-627.
［7］王玲，孙焱．胎膜早破的ICD-10编码［J］．中国病案，2020，21(1)：30-32．DOI:10.3969/j.issn.1672-2566.2020.01.013.
［8］国家卫生计生委办公厅．国家卫生计生委办公厅关于印发住院病案首页数据填写质量规范(暂行)和住院病案首页数据质量管理与控制指标(2016版)的通知［J］．中华人民共和国国家卫生和计划生育委员会公报，2016(5)：28-35.
［9］赵会林．产科梗阻性分娩相关疾病编码案例分析［J］．中国病案，2018，19(10)：20-22．DOI:10.3969/j.issn.1672-2566.2018.10.008.
［10］陈红菊．某院1385份产科住院病案首页主要诊断及编码缺陷分析［J］．中国病案，2021，22(4)：14-17．DOI:10.3969/j.issn.1672-2566.2021.04.006. |
| [1] |
Chen Yanyan, Chen Jieqiong, Wang Qinxu, Wang Xiaomei. Analysis of health education ability of obstetrical nurses and its influencing factors[J]. journal1, 2022, 29(3): 223-227. |
| [2] |
Guo Xusheng, Li Rengang, Xi Yue. Retrospective analysis of the coding quality of International Classification of Diseases for tumors in a tertiary hospital[J]. journal1, 2022, 29(3): 188-191. |
| [3] |
Zhang Rui, Yang Fan. Application case analysis of R coding in ICD-10[J]. journal1, 2022, 29(1): 51-53. |
| [4] |
Zhang Fan, Zheng Jing. Discussion on classification and coding of adult congenital cardiovascular disease and interventional therapy[J]. journal1, 2021, 28(6): 538-541. |
| [5] |
He Jianxia, Zhao Jun, Yang Fahui. Analysis of 90 ambiguous medical records in a tertiary general hospital[J]. journal1, 2021, 28(6): 542-545. |
| [6] |
Liu Jiwei, Zhang Qihua. Analysis on the disease composition of inpatients with malignant tumor in secondary or above medical institutions in a city from 2017 to 2019[J]. journal1, 2021, 28(5): 420-425. |
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